Resident Medical Information Left Unattended and Exposed at Nurse's Station
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records when the Assistant Director of Nursing (ADON) left a piece of paper containing sensitive medical information exposed and unattended on top of the nurse's station countertop. The document included the resident's name, medical record number, physician's name, proposed course of therapy, medication name, and the condition being treated, which was psychotic behavior. The paper was left facing the hallway with no staff present at the nurse's station, making the information visible to anyone passing by. The resident involved was an elderly female diagnosed with depression and unable to complete a cognitive assessment interview. Her care plan included medication management for depression, and her physician's order specified the use of Quetiapine Fumarate. The ADON acknowledged leaving the document exposed and recognized that this action constituted a violation of confidentiality and HIPAA regulations. Both the Director of Nursing (DON) and the Administrator confirmed that resident health information should not be exposed or accessible to unauthorized individuals, as per facility policy.